Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Sunday, September 16, 2007

I recently had the honor of writing a letter of recommendation for a friend of mine who is leaving Emergency Medicine to go back and do an anesthesia residency. This is no small decision. He is going back to four years of low pay, long hours, and the humbling title of 'residenct physician'. I asked him why he was doing this and he wrote me an email that, as I read it, I found myself nodding my head again and again to. So, without further ado, and with his permission, here is his letter to me about why he is leaving Emergency Medicine.

As you remember, this is something I've been thinking about for a while. Basically, over the past couple of years I've become very disillusioned with Emergency Medicine and the direction it is heading. EM has become permeated with too many pseudo-business men who are more concerned with spreadsheets and bottom lines and "customer satisfaction" than they are with promoting the specialty and helping it to evolve. They especially don't seem to care at all about physician satisfaction and well-being. It is my impression that most ED and hospital directors view their docs as a commodity to be used-up and tossed aside when they get burned out. They also don't seem to care that the ED is being used more and more as a walk-in primary care clinic than as an actual emergency room. I didn't go into this field to take care of a bunch of primary care bullshit that FPs and internists should be taking care of in their clinics. I'm also disgusted with the growing sense of entitlement and grandiose expectations of the average ER patient. I had hoped this would change when I moved to a different area of the country. And, while it is better here, it's just not enough for me to see this as a long-term career choice. Also, frankly, I'm getting tired of listening to the same bullshit complaints from the vast majority of whiny, emotionally needy patients that stream into the ER at an ever-increasing rate. Honestly, I'm getting to the point where I hate people in general. I think being in the ER all the time constantly reinforces my impression that people are worthless, and I'm tired of feeling that way. It's just like when my uncle became a cop. He turned into the most miserable misanthrope because he was immersed in the worst side of humanity every day. Therefore, I guess what appeals to me about anesthesia in part is the fact that I don't have to delve too deeply into the social aspects of medicine. My job is to put people to sleep and make sure they don't die during surgery. A lot of the ambiguity and uncertainty that is inherent in EM just isn't there in anesthesia. There's a definite endpoint for each patient encounter. Plus if the patient starts getting on my nerves, relief is just the push of a syringe away. In the meantime I get to do all the things I like about EM, airway and vent management, vascular access procedures, epidurals and spinals, and critical care among others. Also, they're doing some cool cutting-edge stuff in anesthesia like intra-operative TEEs and EEGs among others, plus I can do a critical care fellowship out of anesthesia and actually get boarded in it so that I can find a job with a critical care group. Plus, a friend from EM residency is already out doing her anesthesia residency, and she's loving it. She and I are very similar, and she thinks it's the best decision she's ever made. Every time I talk to her she tells me how happy she is, while I tell her my latest aggravating stories about the ER.

What a load of CRAP!!!(just kidding) He's pretty much nailed it and not a lot can be added. It's sad what we have allowed to happen to EM and even Medicine in general..Hospitalists are the next in line for this shit..That's why I'm going back into Academics..Now I'll be concerned with teaching "core competencies" whatever the hell that means!!Good luck to your friend!!

He nailed it. The "physician satisfaction" doing this day in and day out is nill. I tried to go back and do a rad residency 6 years ago, but with the new medicaid regulation regarding paying for two residencies it was nearly impossible. Maybe with anesthesia it is different. Were it not for my family and the ability to provide well for them, I would have been out of this shit long ago. Because it certainly isn't the warm fuzzy I get after a long ED shift.

Any ER doctor or nurse who gets into ER without expecting that it's at least 50%-60% (perhaps more on overnights) primary care/BS/maligerers/drug seekers is bound to be miserable.

I wish our hospital would build some sort of psych unit specializing in psychosomatic pain syndromes and prescription drug addiction. Every time a BS FF arrives, they are offered tylenol, ibuprofen, toradol and/or admission and nothing else.

i have to disagree with you based on the following. just as the projections the government made fifteen years ago that we would soon be short of primary care docs were very wrong so were the predictions of the direction of emergency medicine.

i know it has been this way since you have been practicing BUT it has not been this way for folks like Oldfart and there was the expectation that the influx of primary care doctors that we have had would unburden the ED of the 'not sick' and the chronically ill.

in fact, EMTALA, and other recent eventualities have had the effect of both decreasing the number of Emergency Departments in the country AND increasing their use.

to say that we should have expected this is monday morning quarterbacking. seems obvious now, but it was anything but obvious ten years ago. at that time it was reasonable to expect that as emergency physicians we would, in fact, get to practice emergency medicine.

we don't. instead, we wade through 10 patients to get to the one emergency patient. it can't go on like this and my friend's departure will be repeated again and again until the crisis is in the availability of emergency physician.

Amen brother. I just wish we had my mom in triage. None of the bullshit would get through. She would say "I raised 7 kids and had a total of 10 ED visits between them in 14 years. Get the hell out of here and find a PCP or wait in line at the university clinic."

Why the hell go from one hospital based discipline to another??? You will still be at the mercy of the nincompoopy hospital administrators. You'll still have to renegotiate your contract with same said nincompoops on a yearly basis, whose only concern is the bottom line.

Sure, as an anesthesiologist you can perhaps work exclusively at the outpatient surgical centers. But even there, you're still not your own boss and have to answer to others!

Mama, don't let your children grow up to be... hospital based doctors.

Damn, I wish I could talk to your friend and straighten him/her out. Sounds like someone need to be "learned" on the business of medicine.

dear charity doc, good to hear from you. where are you? are you working again?

to be fair to my friend i don't think it's so much the 'business' that gets him as the fact that he has come to hate his patients. he really was miserable and this is really not me writing as 'a friend of mine'.

knowing him personally i think this is a good choice for him. sure he will have complaining patients but he will not have any more 'family plans', six to a room, who are there because 'junior had the sniffles two days ago and we just wanted to make sure the others weren't going to get it and oh by the way can i have a work note and a pregnancy test?"

I so love that you wrote that you are not just writing this yourself as "a friend". The thought did cross my mind and it brought back memories of The Brady Bunch where Marcia asks how her "friend" could get rid of her freckles. I think it is possible I watched too much tv as a child.

I have very happy memories of my anesthesiologists for each surgery. One of them said my last words before going unconscious were "try not to kill me, ok? followed immediately with "you are so hot I'd leave my husband for you". He only told me what I said because I asked if I said anything crazy...I think usually they keep that kind of stuff to themselves, right? (I'll pretend the answer is yes and that doctors would never ever laugh at me about the ridiculous things I say)

I've been running a free clinic in Crack City a few days out of the week. Yep, pro bono. It's a building belonging to a local church that had been used as a soup kitchen for the homeless for years. It used to be the main church but the parish had grown and built a new one.

I've moonlighted a few times around the area as favors for some friends in a bind but have not stepped foot back in the "big house".

you are a good soul my friend. again i must re-extend my offer to move to our town and work for our company. i imagine that you might be done with EMed but we have a good situation up here in terms of reimbursement and the best group of docs i've ever worked with. keep it in mind at least and contact me through the blog if you are interested or want more info. cheers and good luck.

Thanks for the offer and the well wishes. I was born in Crack City. I grew up in Crack City and I guess I shall die in Crack City trying to make it a better place.

The good thing, though, is that I'm financially solid. Made some really good/lucky real estate investments on some ocean front and bay front properties long long ago that have went through the roof! And I cashed out over a year ago at the peak of the market, well before things started crashing down this year. SWEET! I bought these lots for cheap, very cheap now that I think about it. My wife is from that area and whenever I we visited her parents, I had a hunch that the sleepy beachside town would grow. But never in my wildest dream did I ever envision such acceleration. It's funny how our capitalistic society work. The more money you have on paper (even though you never see any of it, much less even hold it), the more the banks will let you borrow to buy more properties. I started out with just 2 lots, then with the built up equity, they let me borrow even more money. So I borrowed more and bought even more water front lots. Seeing how water front properties are limitted commodities, I bought as many as I could and paid them all off after 7 years. Then all of the sudden a few years ago, real estate took off like vibrio sepsis in a homeless diabetic. A bunch of condo developers came knocking at my doors wanting to buy my lots to build their resorts and marina. They offered me gobs of 6-figure dollars, so obscene that I couldn't refuse. Thus, I happily sold them. I'm still holding on to 3. One for each of my kids so that they won't be able to say that their old man didn't leave them anything.

Plus, I own Google shares since $98 and Apple since $48/shares, as well as CME (well BOT, right at the IPO offering). I'm financially secure to practice medicine on my own terms.

911- I didn't really mean that Oldfart or your-friend-who-sounds-a-lot-like-you-2-weeks-ago should have expected it to be how it is today---all I meant was that if he was expecting (for whatever reason) ER to be mainly emergencies and got into ER to deal with emergencies, he and most other people will surely be miserable. I was, admittedly, even a little disappointed when I realized how few of my patients were emergency patients. Not like the TV show where even sore throat patients routinely code.

charity doc. good for you. many continued blessings. used to live in your part of the country, i think. real estate is the best investement we have ever made but we have not been Trump-ish like you. nice to not have to worry.

nurse K, no offense taken. i too will leave this 'business' soon and will let everyone know why and when. plans ongoing.

What a treat to find out what happened to you, Charity. I'm so happy that you're doing well and doing what you want to do.

What really saddens me is to see good docs leaving medicine because of the all the crap you have to put up with. You all worked so hard to reach this goal, and it's...well...heartbreaking. Just promise me, kids, that my next doc visit won't be to a veterinarian, okay?

Our dept chief is married to a Gen Surg, so you'd think they'd be cool. But he recently told me she's seriously thinking of trying to get into Vet school! She hates her pts as much as we do.He says he'd put up with 4 yrs of vet school for her as long as he got to quit when she finished! Or else come work for me when I get my EM residency up and reunning!

One thing that you might consider, to any are pissed about emergency medicine in a big city, is moving to a really small town with the only hospital in a 40 minute drive.

I lived in such a place and worked in EMS in such a place. Now I live in Big Dangerous Urban City and while I see a lot more critical calls and keep my skills sharp, I also see a lot more malingering and bullshit than has ever existed in the last 1000 years in rural community X.

People in small towns, by small I mean like 25,000 or smaller, don't go to the hospital until they've run their hand through the corn auger or scalped themselves on the PTO.

If they get a nail in their foot, they pull it out with a pliers and only go to the hospital when it turns in a massively swollen basketball of hot green pus.

You might get awful bored sitting in an empty ER watching the first five seasons of Sopranos on DVD until a patient walks in with a apenic and blue baby, but you'll see real people with real problems and be the only physician in an hour drive. Nobody to consult with, nobody specialist to come down, just you.

Look at Wyoming, South Dakota, North Dakota, northern Minnesota, Montana. Small towns in those places don't always have well run hospitals, and don't always pay the best, but you can live cheaply, and people will be genuinely appreciative of your help.

You'll be The Doctor in those towns. Maybe the old days of the black bag aren't your thing, but a lot of physicians write it off as being beneath them. It's a shame, because places like that need good people, want good people, and are happy to have good physicians in town.